Provider Demographics
NPI:1780190587
Name:MERMOLIA, ASHLEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:MERMOLIA
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S88W19381 TIMBERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-7860
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IL
Practice Address - Zip Code:62254-1291
Practice Address - Country:US
Practice Address - Phone:414-587-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-17
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X, 390200000X
IL0960052272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program